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Background: Equipoise exists between the use of leaflet resection and preservation for surgical repair of mitral regurgitation caused by prolapse. We therefore performed a randomized, controlled trial comparing these 2 techniques, particularly in regard to functional mitral stenosis. Methods: One hundred four patients with degenerative mitral regurgitation surgically amenable to either leaflet resection or preservation were randomized at 7 specialized cardiac surgical centers. Exclusion criteria included anterior leaflet or commissural prolapse, as well as a mixed cause for mitral valve disease. Using previous data, we determined that a sample size of 88 subjects would provide 90% power to detect a 5–mm Hg difference in mean mitral valve gradient at peak exercise, assuming an SD of 6.7 mm with a 2-sided test with α=5% and 10% patient attrition. The primary end point was the mean mitral gradient at peak exercise 12 months after repair. Results: Patient age, proportion who were female, and Society of Thoracic Surgeons risk score were 63.9±10.4 years, 19%, and 1.4±2.8% for those who were assigned to leaflet resection (n=54), and 66.3±10.8 years, 16%, and 1.9±2.6% for those who underwent leaflet preservation (n=50). There were no perioperative deaths or conversions to replacement. At 12 months, moderate mitral regurgitation was observed in 3 subjects in the leaflet resection group and 2 in the leaflet preservation group. The mean transmitral gradient at 12 months during peak exercise was 9.1±5.2 mm Hg after leaflet resection and 8.3±3.3 mm Hg after leaflet preservation ( P =0.43). The participants had similar resting peak (8.3±4.4 mm Hg versus 8.4±2.6 mm Hg; P =0.96) and mean resting (3.2±1.9 mm Hg versus 3.1±1.1 mm Hg; P =0.67) mitral gradients after leaflet resection and leaflet preservation, respectively. The 6-minute walking distance was 451±147 m for those in the leaflet resection versus 481±95 m for the leaflet preservation group ( P =0.27). Conclusions: In this adequately powered randomized trial, repair of mitral prolapse with either leaflet resection or leaflet preservation was associated with similar transmitral gradients at peak exercise at 12 months postoperatively. These data do not support the hypothesis that a strategy of leaflet resection (versus preservation) is associated with a risk of functional mitral stenosis. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier NCT02552771.

Introduction: Chronic ischemic mitral regurgitation (MR) has been associated with poor long-term survival. Suboptimal midterm results have been a growing concern in the surgical community. In recent years, our approach to repair those valves has evolved to a standardized technique using complete, rigid and small annuloplasty rings. This study aims to compare this systematic approach with our prior experience from 1996 –2001 where recurrent MR rate was high. Methods: 129 patients underwent repair for pure ischemic mitral valve regurgitation between 2002 and 2005 at our institution. Of these patients, 99 had clinical and echographic follow-up. These patients were compared to the 1996 –2001 cohort of 73 patients. Results: Preoperatively, 84% of patients were in NYHA class III or IV, 17% had moderate MR, 83% had moderate-severe to severe MR. Sixteen were redo operations, mostly of previous CABG. All patients except one were treated with a complete rigid ring (Annuloflo 46.5%, Physioring 34.9%, Etlogix 13.9%, others 3.8%). Ring size was: 24 (0.8%); 26 (55.8%); 28 (38%); or 30 (4.5%). Mortality was 8.5% at 30 days, 14.7% at 1 year and 17.8% at 2 years. Immediate postoperative regurgitation was absent or trace in all patients. Freedom from reoperation was 97%. Mean postoperative NYHA class was 1.15 at a mean follow-up of 28 months. Recurrent moderate mitral regurgitation (2+) was 15.34%, severe mitral regurgitation (3+ to 4+) was 13.4% at a mean follow-up of 16 months. In the 73 patients from the period 1996 –2001 at the same echo follow-up time, the moderate and severe recurrence were: 37% and 21%. The decrease in the recurrence rate was highly significant (p=0.001). Conclusion: A more standardized approach to ischemic mitral valve repair has improved the high recurrence rate previously reported by our group. Long-term follow-up is necessary to confirm these findings.

Background— Off-pump coronary artery bypass surgery (OPCAB) is currently used as an alternative to conventional “on-pump” surgery, but there are very little data available on long-term follow-up. The aim of this study was to review our long-term experience with the use of systematic OPCAB. Methods and Results— 1000 consecutive OPCAB surgeries were systematically performed between 1996 and 2004, representing 95% of all coronary revascularization during that same time frame, with a 97% complete follow-up. Average age of the patients was 64±10 years (778 men and 222 women). Seventy-three percent had triple-vessel disease. Operative 30-day mortality was 1.6%. Overall survival at 96 months was 74±3.5% and cardiac survival was 94±1.3%. By Cox regression analysis, age (odds ratio [OR], 1.07), congestive heart failure (CHF) (OR, 1.90), peripheral vascular disease (OR, 1.74), chronic renal insufficiency (OR, 2.04), previous myocardial infarction (MI) (OR, 1.60), and New York Heart Association functional class (OR, 1.60) were risk factors for long- term mortality. Survival free of any cardiac events (cardiac death, MI, unstable angina, heart failure, or reintervention) was 80±3.4%. Survival free of any type of reintervention alone was 90±3%. By Cox regression analysis, mitral regurgitation (OR, 2.3), peripheral vascular disease (OR, 2.1), and diffuse coronary disease (OR, 2.3) were significant predictors of recurrent cardiac events. Conversion to “on-pump” (OR, 14.3) was predictor of long-term need for repeat revascularization. Conclusion— In this series, systematic OPCAB surgery was shown to be an acceptable alternative to conventional “on-pump” coronary artery bypass graft for the treatment of coronary artery disease.

A 50-year-old man had undergone transcatheter low-energy DC ablation for symptomatic Wolff-Parkinson-White syndrome at 35 years of age. By a retrograde aortic approach, a left lateral bidirectional accessory pathway had been ablated with 7 pulsed 20-J shocks through a 7F quadripolar deflectable catheter (Mansfield-Webster, Watertown, Mass). This catheter was connected to a custom-made box incorporating a high-tension relay, allowing for the delivery of anodal shocks while simultaneously recording intracardiac electrograms and surface ECG leads. The indifferent electrode consisted of a large patch positioned …

Background Off-pump coronary artery bypass surgery (OPCAB) has been revived and has gained popularity, although the exact subsets of patients who might benefit most from this technique are unknown. The aim of this retrospective study was to compare the results of coronary artery bypass grafting surgery (CABG) in octogenarians using cardiopulmonary bypass (CPB) or OPCAB techniques. Methods and Results Over a 5-year period (1995–1999), 125 patients older than 80 years of age were operated for isolated myocardial revascularization (63 using CPB and 62 with OPCAB). There was no statistically significant difference in preoperative comorbidities between groups or in mean left ventricular ejection fraction (54.5±15.3% in the CPB group and 50.9±13.5% in the OPCAB group, respectively). The mean number of distal anastomosis per patient was 2.9 in CPB group and 2.6 in OPCAB group ( P =ns). The majority of patients in both groups had unstable angina and were operated on an urgent basis. The operative mortality was 15.9% in the CPB group and 4.8% in the OPCAB group ( P =0.04). There were 4 postoperative strokes (6.3%) in the CPB group and none (0%) in the OPCAB group ( P =0.04). The percentage of patients transfused was 92.1% in the CPB group and 72.6% in the OPCAB group ( P P =NS). For all the parameters entered in the multivariate analysis with logistic regression model, the type of surgery (CPB or OPCAB) was an independent predictor of operative mortality and stroke ( P =0.0375). The odds ratio (OR) indicates that operative mortality and stroke occur 4 times (OR=4.171) more often in CPB patients than in OPCAB patients. Follow-up showed no significant difference between the 2 groups in terms of cardiac events and mortality. Conclusions This retrospective study suggests a benefit of OPCAB in terms of operative mortality and stroke for octogenarian patients when compared with CPB in our institution.